Healthcare claim transactions, such as prescription claim requests, are often routed from a healthcare provider, such as a pharmacy or hospital, to a claims processor through a service provider system. Typically, a healthcare provider communicates a healthcare claim transaction to a service provider, and the service provider routes the healthcare claim transaction to an appropriate claims processor, such as an appropriate insurance provider or other payer. Following adjudication of the healthcare claim transaction by the claims processor, the service provider typically receives an adjudicated reply from the claims processor and routes the received adjudicated reply to the healthcare provider.
During periods of high volume traffic and/or during periods in which the claims processor or payer is experiencing technical difficulties, a healthcare claim transaction may be rejected by the service provider due to a host error associated with the claims processor. In these situations, a suitable rejection code is typically returned to the healthcare provider informing the healthcare provider of the error and instructing the healthcare provider to resubmit the claim at a later point in time. However, in some situations, the healthcare provider will not resubmit the claim, thereby resulting in lost revenue for the healthcare provider. Additionally, in the event that the claim is resubmitted, there is a chance that the claim will be rejected by the claims processor as a duplicate claiming, leading to healthcare provider confusion and administrative difficulties.
Therefore, a need exists for systems and methods for processing healthcare claim transactions that are rejected as a result of a host error.